billing a meds management visit as psychotherapy

[istillbelieve]

Psychiatrists in our state normally see meds managment patients for 15 minutes. If the visit goes just one minute over the 15 minutes, many docs are billing the visit as a psychotherapy visit. I know they are allowed to do this. I think I would feel uncomfortable doing this if it went only a minute over, when nothing near psychotherapy took place. Thoughts.

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[Shikima]

You can't. Psychotherapy visits have strict criteria associated with it. A med visit would be billed typically as a 99213, 214 if you're checking labs. The psychotherapy riders would include start and stop codes indicating you've been in session for X minutes, usually 45.

 

[istillbelieve]

Mistake

 

[jettavr6]

99213 + 90833 if it goes past 16 minutes, and if there was therapy involved. If there was no therapy involved, then you cannot bill the 90833

 

[Shikima]

99213 + 90833 if it goes past 16 minutes, and if there was therapy involved. If there was no therapy involved, then you cannot bill the 90833

That sounds about right!

 

[istillbelieve]

99213 + 90833 if it goes past 16 minutes, and if there was therapy involved. If there was no therapy involved, then you cannot bill the 90833

Before I was a med student I worked in a psychiatrist's office. This doctor was actually billing for psychotherapy when no such thing took place. In other words, he was using the 90833 cpt code along with the 99213 code as long as the meds visit went over 16 minutes. A patient had been researching this. She worked for an insurance company. She then put 2 and 2 together and left his practice. It was too bad; he was a lot of help to her.

 

[Fenster]

Before I was a med student I worked in a psychiatrist's office. This doctor was actually billing for psychotherapy when no such thing took place. In other words, he was using the 90833 cpt code along with the 99213 code as long as the meds visit went over 16 minutes. A patient had been researching this. She worked for an insurance company. She then put 2 and 2 together and left his practice. It was too bad; he was a lot of help to her.

I'm sure there were other equally able psychiatrists who could do her "med management" so don't worry about her still!

 

[istillbelieve]

I'm sure there were other equally able psychiatrists who could do her "med management" so don't worry about her still!

You are right.

You know it gets pretty tricky: He may have given her supportive counseling during the (just guessing) that short period of time. He may consider supportive counseling psychotherapy. But, who knows.

 

[hamstergang]

Psychiatrists in our state normally see meds managment patients for 15 minutes. If the visit goes just one minute over the 15 minutes, many docs are billing the visit as a psychotherapy visit.

I made a mistake. It seemed like this: If a medication visit went to 30 minutes, it was billed as a psychotherapy visit.

This doctor was actually billing for psychotherapy when no such thing took place. In other words, he was using the 90833 cpt code along with the 99213 code as long as the meds visit went over 16 minutes.

Do you plan on changing your mind again on whether you're talking about 16 or 30 minutes?

 

[hamstergang]

fell victim to the double posting

 

[istillbelieve]

"Do you plan on changing your mind again on whether you're talking about 16 or 30 minutes?"

No, no change of mind. I was thinking about another post when I wrote this. I was very tired when posting. Anyway, I am talking about the 16 minute rule. I will change the other post to 16. That is what I meant. I have never seen a visit go for 30 plus minutes (at least not with the doctor I worked for), unless it was a patient's first visit (history visit).

 

[TexasPhysician]

Before I was a med student I worked in a psychiatrist's office. This doctor was actually billing for psychotherapy when no such thing took place. In other words, he was using the 90833 cpt code along with the 99213 code as long as the meds visit went over 16 minutes. A patient had been researching this. She worked for an insurance company. She then put 2 and 2 together and left his practice. It was too bad; he was a lot of help to her.

That is appropriate if 16 minutes all involved supportive therapy. I am under the impression that it would be hard to discuss meds while also being supportive - I'd say that would be more educational. Therefore if I bill 90833, the visit must be longer than 16 minutes.

 

[istillbelieve]

That is appropriate if 16 minutes all involved supportive therapy. I am under the impression that it would be hard to discuss meds while also being supportive - I'd say that would be more educational. Therefore if I bill 90833, the visit must be longer than 16 minutes.

He did say that he listened to her talk about her problems and experiences. He never really gave feedback from what she told me, just a gesture or a one word response. But, he would make sure to tell her, "that is for you and your therapist to work on." Her meds management was very complex. Most of the time she would come out between 16 and 18 minutes. Sometimes she took 20 minutes.

I agree. I think that it is difficult to do both in that short amount of time. In her case, it would be almost impossible given that her medication situation is so complex.'

 

[istillbelieve]

If she is almost sure about this. She should call the complaint line and have him investigated. Why should patients with private insurance have to pay more when he is committing fraud (IF this is what is happening). I sure don't want to see a psychiatrist and have he/she rip me off for something that never took place.

 

[SuperSoccer19]

Before I was a med student I worked in a psychiatrist's office. This doctor was actually billing for psychotherapy when no such thing took place. In other words, he was using the 90833 cpt code along with the 99213 code as long as the meds visit went over 16 minutes. A patient had been researching this. She worked for an insurance company. She then put 2 and 2 together and left his practice. It was too bad; he was a lot of help to her.

I didn't think the 90833 code even came out until the 2013 changes? Before it would have been either a separate E&M code only or something like a 90805 (which includes the therapy plus E&M, unlike the new codes)? I didn't think it was even possible to bill for a 99213 plus what would have been a 90805 (or whatever the separate code) was? When I was learning to code I got dinged for that as a resident, but I could be wrong.

 

[michaelrack]

If he did commit fraud, which may be the case, I hope she calls the complaint line and turns him in. Why should patients with private insurance have to pay more when he is committing fraud. If this is what is happening.

It's going to be hard to prove fraud, especially if the doc spent sufficient time with the patient. What qualifies as psychotherapy is very subjective.

 

[istillbelieve]

It's going to be hard to prove fraud, especially if the doc spent sufficient time with the patient. What qualifies as psychotherapy is very subjective.

This is what I said earlier. I mentioned that some docs consider supportive counseling to be psychotherapy. Some don't.

What does sufficient time mean? If the doc spent "sufficient time" with patients, what was he doing? Was he doing meds mangagement. supportive counseling, or both? I know that psychotherapy can hardly be done if one has a complex med case. But, it does go back to how the doc defines psychotherapy.

 

[splik]

what do you mean by "supportive counseling" - supportive therapy is a psychotherapy that is billable. as far as CMS is concerned if it is for the purposes of direct therapeutic benefit it is psychotherapy. where things get iffy is when people bill 'counseling and coordination of care' as psychotherapy which is not allowed. for example, if you are talking to a pt about different med options or exploring their resistance to take meds, that is 'counseling and coordination of care' and not 'psychotherapy'.

 

[istillbelieve]

Care coordination sounds like something a social worker would do. I agree this is definitely not psychotherapy.

I always thought that supportive counseling (some call it this as my former workplace did) was a light form of psychotherapy. This is because it can get deep some of the time.

 

[notdeadyet]

I always thought that supportive counseling (some call it this as my former workplace did) was a light form of psychotherapy. This is because it can get deep some of the time.

Are you using supportive counseling as synonymous with supportive psychotherapy?

 

[michaelrack]

This is what I said earlier. I mentioned that some docs consider supportive counseling to be psychotherapy. Some don't.

What does sufficient time mean? If the doc spent "sufficient time" with patients, what was he doing? Was he doing meds mangagement. supportive counseling, or both? I know that psychotherapy can hardly be done if one has a complex med case. But, it does go back to how the doc defines psychotherapy.

By sufficient time, I mean that the doctor spent at least the minimum amount of time with the patient to bill the psychotherapy code ( I am not too familiar with the codes and can't give a more detailed answer). I guess I mean that he spent enough time with the patient to plausibly claim to meet the requirements of the code.

 

[istillbelieve]

By sufficient time, I mean that the doctor spent at least the minimum amount of time with the patient to bill the psychotherapy code ( I am not too familiar with the codes and can't give a more detailed answer). I guess I mean that he spent enough time with the patient to plausibly claim to meet the requirements of the code.

He spends enough time to meet the psychotherapy code. But, he tells patients and his staff that he does not do psychotherapy at all. He listens to patients and gives a nod or two (the patient told me). But, he barely replies to anything any patient says, unless it is having to do with meds. From what patients told me, he was rather abrupt with patients that weren't always focused on meds.

 

[istillbelieve]

Are you using supportive counseling as synonymous with supportive psychotherapy?

I have never really heard of supportive counseling. At the pp I worked at, I have never heard of either one.

He only did meds education. From what patients told me, he listened briefly to problems and made a comment or two.

 

[notdeadyet]

I have never really heard of supportive counseling. At the pp I worked at, I have never heard of either one.

Ah. Google supportive psychotherapy. It's an actual thing with technique if you do it properly. Supportive counselling sounds like an adjective + noun.

 

[istillbelieve]

Ah. Google supportive psychotherapy. It's an actual thing with technique if you do it properly. Supportive counseling sounds like an adjective + noun.

Ok. I just googled supportive psychotherapy. He definitely wasn't doing that. He was just listening to problems/stories, barely responding to anything, and doing meds education. Then he billed the visits as psychotherapy. Since he billed them as psychotherapy (I saw parts of the forms), I wonder how he described his "psychotherapy" sessions. If he is committing fraud, the patients with private insurance have to pay more for nothing. Even if they aren't paying for the visit (medicaid, welfare), it is still wrong. I think the patient that stopped seeing him may report him. She was really angry.

Maybe I should warn him. After all, I worked for him. Thoughts?

He really is a good psychiatrist. I'd like to work for him or be a partner, although it would be several years down the road. Before I started medical school, I expressed this wish to him. He was rather positive.

 

[Shikima]

He's maximizing his profit margin. Similar cases with the candyman syndrome - come in for a BZD or Amphetamine script and gone in 15 minutes.

 

[billypilgrim37]

This is clearly fraud from an ethical standpoint. Whether it's fraud from a legal standpoint is less clear. I don't think it would be hard to prove it as fraud, as the lowest psychotherapy code requires 16 minutes to be devoted to psychotherapy for the add on. If they're claiming a 16 minute psychotherapy session, then they're saying they spent 0 minutes performing E&M services, because the time must be separated, and there are general guidelines for how long various levels of service should take. A 99213+lowest psychotherapy code would probably need to average at least a 25 minute session to stand up to scrutiny, and even that would be pushing it. If you have lots of no shows and could make the time work, it might be arguable. But if you're seeing 3-4 E&M+psychotherapy patients an hour consistently, there's now way that would hold up in an audit.

What the OPs colleagues seem to be missing is that a) psychotherapy has definitions under these guidelines, b) supportive psychotherapy is an actual technique, and c) the E&M time and the psychotherapy time MUST be separate.

For example, from talking with folks at the APA, if you spent 20 minutes doing motivational interviewing with someone, that does NOT meet the definition for psychotherapy, but is rather considered counseling and coordination of care. Psychoeducation is counseling not psychotherapy, et al.

 

[Shikima]

Correct. Documents would have 2 individual start/stop times to indicate you've done E&M+Psychotherapy.

 

[istillbelieve]

Thank you for your responses.

It is obvious he wasn't doing psychotherapy. It does make sense that it would be almost impossible to do E & M + psychotherapy and have the patient out in such a short time. This is especially the case with patients like the woman that left. Her med management is very complex.

This is not really relating to the thread: Why are psychiatrists even doing therapy, if a patient has a psychologist? If a patient is in therapy already, I don't think the psychiatrist should be doing any psychothery. Having two providers doing therapy, can get confusing for the patient. Psychotherapy is very intense and hard work for both the provider and the client. It should not be "undermined" (for lack of a better word) by another provider. This is why there are psychiatrists that want to do meds management and psychotherpy. They feel that the prescriber should "know" the patient very well. I have run into a few of them. It seems like more of the older docs feel this way.

 

[medicaresucks]

Why are you so obsessed with this anyways. I do 5 min med management and 16 min therapy on most patients. if your that worried call the police.

/thread

Thank you for your responses.

It is obvious he wasn't doing psychotherapy. It does make sense that it would be almost impossible to do E & M + psychotherapy and have the patient out in such a short time. This is especially the case with patients like the woman that left. Her med management is very complex.

This is not really relating to the thread: Why are psychiatrists even doing therapy, if a patient has a psychologist? If a patient is in therapy already, I don't think the psychiatrist should be doing any psychothery. Having two providers doing therapy, can get confusing for the patient. Psychotherapy is very intense and hard work for both the provider and the client. It should not be "undermined" (for lack of a better word) by another provider. This is why there are psychiatrists that want to do meds management and psychotherpy. They feel that the prescriber should "know" the patient very well. I have run into a few of them. It seems like more of the older docs feel this way.

 

[Shikima]

Why are you so obsessed with this anyways. I do 5 min med management and 16 min therapy on most patients. if your that worried call the police.

Yeah.... I'm not going to touch this with a 10' pole.

 

[istillbelieve]

Why are you so obsessed with this anyways. I do 5 min med management and 16 min therapy on most patients. if your that worried call the police.

I think we tend to forget that we are also patients too. Imagine you having a doctor that could be committing fraud and having to pay more because of it. If a doctor bills it as psychotherapy, the patient has to pay more. Think about yourself or your patients having to pay more for something that didn't happen.

This is someone I wanted to work for or practice with because he is a very good doctor. If he is committing fraud, I question his morals.

If you can't even imagine yourself in the position of his patients, what are you doing in a field like psychiatry.

 

[istillbelieve]

Yeah.... I'm not going to touch this with a 10' pole.

The same goes for you too.

 

[medicaresucks]

Listen. The bigger issue with all of this is the insurance companies pay is next to horrible. Most likely medicare paying 70$ for a level 3 visit and 40 dollars for add on therapy isn't much better. The advent of EMR has made a drastic upcoding trend in medicine.. level 3's become level 4 etc. Some of this is because of undercoding in past but there is more incentive to upcode now than ever. Be happy that your psychiatrist was even spending 15 min with a pt. Many i've seen who do no therapy spend 5-6 minutes on strict med management issues. Compared to other fields those in psychiatry spend much more time per patient than 0thers and im speaking for those who aren't doing therapy as well. A sustainable solo PP psychiatrist cannot easily do 30 min visits on a regular basis. Some may be cash based but for the vast majority 15-20 min visits is the norm. Go back to studying and stop being obsessed with what others in PP are doing. Its their business. pun intended.

 

[Shikima]

Rage much bro?

 

[billypilgrim37]

Listen. The bigger issue with all of this is the insurance companies pay is next to horrible.

No, that is an ENTIRELY different issue that has nothing to do with this whatsoever. Just because someone won't pay you what you think you need to make for your services doesn't justify unethical behavior. And people SHOULD be worried about unethical behavior, because it typically punishes those who at least try to be ethical.

 

[istillbelieve]

Listen. The bigger issue with all of this is the insurance companies pay is next to horrible. Most likely medicare paying 70$ for a level 3 visit and 40 dollars for add on therapy isn't much better. The advent of EMR has made a drastic upcoding trend in medicine.. level 3's become level 4 etc. Some of this is because of undercoding in past but there is more incentive to upcode now than ever. Be happy that your psychiatrist was even spending 15 min with a pt. Many i've seen who do no therapy spend 5-6 minutes on strict med management issues. Compared to other fields those in psychiatry spend much more time per patient than 0thers and im speaking for those who aren't doing therapy as well. A sustainable solo PP psychiatrist cannot easily do 30 min visits on a regular basis. Some may be cash based but for the vast majority 15-20 min visits is the norm. Go back to studying and stop being obsessed with what others in PP are doing. Its their business. pun intended.

Your post states this: Because I am homeless and can't afford to buy food, it is alright to steal from the store. Committing fraud (patients having to pay more for a service that did not take place, etc) is no different than stealing from the store. No difference Brah!

And it does become our business when this happens.

I question your morals. So go back to your residency program and learn about morals. It is too bad that you didn't learn about this stuff earlier.

 

[medicaresucks]

Im not stealing from the store. I am cash pay only and dont accept any type of insurance what so ever. I can charge whatever the market in my area bears. And frankly I dont give a damn what other people in private practice do. Good luck with that.

 

[istillbelieve]

No, that is an ENTIRELY different issue that has nothing to do with this whatsoever. Just because someone won't pay you what you think you need to make for your services doesn't justify unethical behavior. And people SHOULD be worried about unethical behavior, because it typically punishes those who at least try to be ethical.

Totally agree!!!

 

[istillbelieve]

Im not stealing from the store. I am cash pay only and dont accept any type of insurance what so ever. I can charge whatever the market in my area bears. And frankly I dont give a damn what other people in private practice do. Good luck with that.

I didn't say that you were stealing from the store. I meant that stealing is stealing. You should already know what I mean. But, I am having to spell it out for you. If you don't understand that, I wonder if you really are a doctor.

If you don't give a damn, why are you even responding to my posts.

And I wish you luck, because MANY, MANY, MANY people want to use their insurance plans and not pay out of pocket.

 

[splik]

this is the problem with fee for service! i will avoid going off on my dirty socialist rant about how the whole healthcare system should be nationalized, but fee for service is a fertile soil for fraud. what is just as pernicious if you ask me is performing services that are unnecessary in order to increase how much you can bill for. this has happened to me and i am much more sympathetic to how much things will cost patients.

 

[Shikima]

this is the problem with fee for service! i will avoid going off on my dirty socialist rant about how the whole healthcare system should be nationalized, but fee for service is a fertile soil for fraud. what is just as pernicious if you ask me is performing services that are unnecessary in order to increase how much you can bill for. this has happened to me and i am much more sympathetic to how much things will cost patients.

The fee for service isn't necessarily a soil for fraud. It's the actions behind the practioner. Can't confuse the two - that would be throwing the baby out with the bath water. We can call into question practice ethics and how effective his therapeutic model is based on what has been posted here. And we have ample evidence of practitioners who commit medicare/medicaid fraud daily (recently a heme/onc in Detroit was accused of millions of dollars in fraud).

So, single payer health system wouldn't solve this (nor implemented because the Gov't doesn't know what it's doing 5/6 of the time).

 

[istillbelieve]

The fee for service isn't necessarily a soil for fraud. It's the actions behind the practioner. Can't confuse the two - that would be throwing the baby out with the bath water. We can call into question practice ethics and how effective his therapeutic model is based on what has been posted here. And we have ample evidence of practitioners who commit medicare/medicaid fraud daily (recently a heme/onc in Detroit was accused of millions of dollars in fraud).

So, single payer health system wouldn't solve this (nor implemented because the Gov't doesn't know what it's doing 5/6 of the time).

Yes, this is true. There is a doc that accepts only cash. His patients like him. He takes call 24 hours a day. He is certainly not ripping off his patients. This is an example of a cash pay only doc not committing fraud but going over board for his patients. I don't know how he can recharge his batteries.

Wow, that is really sad about the heme onc situation.

 

[billypilgrim37]

The fee for service isn't necessarily a soil for fraud.

Sure it is. There are incentives to rack up bills and do things that will get paid for. People respond to incentives, ethically or unethically.

Fee for service (or not) has nothing to do with single payer or any government run healthcare.

 

[Shikima]

Sure it is. There are incentives to rack up bills and do things that will get paid for. People respond to incentives, ethically or unethically.

Fee for service (or not) has nothing to do with single payer or any government run healthcare.

I appreciate the sentiment, however, I disagree. It's a matter of Primium Integreate - Integrity first. Are you doing the right thing when no one is looking. A single pay source will not correct this personality dysfunction, it's already integral into the person's behavior.

 

[billypilgrim37]

Single payer has nothing to do with fee-for-service. You're conflating two entirely different things.

 

[billypilgrim37]

I appreciate the sentiment, however, I disagree. It's a matter of Primium Integreate - Integrity first. Are you doing the right thing when no one is looking. A single pay source will not correct this personality dysfunction, it's already integral into the person's behavior.

and that's REALLY inaccurate latin...

 

[Shikima]

Irrespective of the red herring call out, I contend that ethical practioner behavior remains the point of contention.
I'm quite surprised that NONE of us (including me) haven't spoken out against 15 mins med checks - we all continue forward as lemmngs to the cliff citing "that's business".

 

[TexasPhysician]

Irrespective of the red herring call out, I contend that ethical practioner behavior remains the point of contention.
I'm quite surprised that NONE of us (including me) haven't spoken out against 15 mins med checks - we all continue forward as lemmngs to the cliff citing "that's business".

I will never do 15 min med checks unless seeing a stable patient daily in a detox/rehab facility. Otherwise never. 20 min minimum as I prefer to include therapy with treatment.

 

[Shikima]

I will never do 15 min med checks unless seeing a stable patient daily in a detox/rehab facility. Otherwise never. 20 min minimum as I prefer to include therapy with treatment.

Thank you.